Project Summary The population is aging and according to the United States (U.S.) Census Bureau, the proportion of adults aged 65 and older is projected to grow from 15% in 2015 to 24% in 2060. This rapidly growing segment of the population constitutes a large part of the surgical care provided in the U.S. These numbers will expand in the coming years and the demand for surgery in older adults will continue to increase. Pain management is becoming an increasingly important topic in perioperative care and is of particular importance in the older adult. Very little research has been focused on pain management issues specific to older adults and is a significant research gap that the current proposal will fill. While experts agree that use of a multimodal pain plan is important for high quality surgical care of the older adult, we do not know the key components that should be included. Significantly more work is needed to develop an individualized and patient-centered multimodal pain plan for older adults undergoing surgery. The current proposal has the following three specific aims: (1) Measure the association between presence of a hospital level pain management strategy for older adults and geriatric specific outcomes of postoperative delirium and functional decline using data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Geriatric Surgery Pilot Project; (2a) Develop candidate evidence-based standards for an opioid sparing multimodal pain protocol for older adults undergoing surgery; (2b) Quantify the validity and feasibility of candidate standards for an opioid sparing multimodal pain protocol using a multidisciplinary panel and the RAND/UCLA Appropriateness Methodology; (3) Pilot test an opioid sparing multimodal pain management protocol using the standards identified in Aim 2 to assess adequacy of pain control and feasibility from the patient, family member, and provider perspective. The outcome of the current proposal will be a valid and feasible opioid sparing multimodal pain management protocol. This work is important to identify the key elements of a postoperative pain management protocol specific to the unique perioperative needs of older adults. Development of an opioid sparing multimodal pain management protocol for older adults undergoing surgery will potentially minimize geriatric-specific outcomes like postoperative delirium and could ultimately be implemented at any hospital interested in improving care for older adults undergoing surgery. More attention to pain management in this vulnerable population using standardized processes of care is needed to provide safe, high quality, and patient-centered care.